Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Friday, May 30, 2008

Here's a Georgia O'Keefe painting called "Jack in the Pulpit no. I V." Nice.

On a completely different subject, what is it about physicians that makes us pussies? Somehow the previous generation of physicians rolled over and ate a huge shit-sandwich from the government called EMTALA. Our national organizations, the AMA, ACEP and the like, have acted like a bunch of perpetually-stoned good-time rock and roll maggot-infested hippies and have embraced the fucksticks at JCAHO too.

I know that the premed route is not exactly peppered with economics, logic, or business classes but please, you freaking douchebags, how in the name of all that is holy did you swallow the EMTALA and JCAHO pills? How, exactly, can you provide CABGs for all regardless of their ability to pay? The answer is, you can't, but while trying to accomplish this ass-hattery you will do it by having everybody else pay for it. In other places this is called stealing.

Could you not see, if only from a rudimentary common sense perspective, that EMTALA was going to crush you? Did you not know that when unfunded mandates have been tried previously, or their ugly father called communism, that they have failed miserably and made the situation worse?

Where were you, docs? Out on the golf course? Why were you not on the steps of Capitol Hill marching and carrying signs and threatening to strike? Why? Are you all a bunch of pussies or did you figure that by the time EMTALA ruined medicine that you would be comfortably retired? Damn your eyes for being clueless pussies because not only did you screw the next generation of doctors, you screwed the next generation of patients too.

That IS what happened, OR, in your feel-good liberalism you knew, you knew deep-down, that EMTALA would end fee-for-service and force a "solution" from above because you love government and its power and revere it with religious zeal. Better that all be in a similar state of misery than some have it better than others. OR, you were too busy working, and didn't think your colleagues and national organizations could be that stupid. WRONG!

Well good for you sunshine. Why don't you just move to some socialist heaven with closed borders and frozen social classes and live there. In the meantime you have made being an ER doc, or a doc that gets consults from me, an endless parade of entitled asswipe misery, and you have sucked the soul right from my body. You have wrecked specialty care for everyone outside of a big city. You have also wrecked the best care for the most system which we had and replaced it with mediocre care for all.

Happy now? I thought not, because there are still some in America who have more than others. Still, some rich folks get better care than that guy who ran his stolen car into a bridge abutment, drunk, while running from the police. How will you fix that? Why not go all the way and join the American Communist Party. Fucksticks. Have fun driving your Prius and drinking soy and wheat-grass shakes. Guess what? You are going to die too. Double fuckstick Deborah Peel in your face asswipedouchebags.

It isn't that we are pussies. Try calling the on-call surgeon at 3am about an uninsured kid with appendicitis, without a CT scan. Certainly no tiny kitten with big eyes and a a quivering lower lip there. The more appropriate term for the resulting conversation would be a "crap splatter".

The original intent of EMTALA was to prevent the hospital from doing a wallet biopsy in order to determine if that uninsured transected aorta was stable enough to go to the county hospital. With a negative biopsy, the pressure was on to transfer. And it happened. It was only a matter of time until news shows, like 60 Minutes, jumped on it. The result was the original definition of a paradox... get the government to save us.

And, as every person who has sported the moniker of Defendant in a malpractice case claims, it seemed like a good idea at the time. What could possibly go wrong?

Well, EMTALA was agar to the rectal bacteria called government. Multiplying exponentially with all the food and warmth EMTALA provided, the government took what was an eagle of an idea and sucked it through a jet engine. So feast on the bird bits we have now.

Meanwhile, the docs at the time were busy being the moles in the whack-a-mole of the legal system and government. Best to keep your head in the tunnel. Organizations like the AMA and ACEP became infested with physician-politicians, proving Darwin was wrong. Put 10 of these pig humping lizards in a meeting and you get, well, more meetings. And higher dues.

The medical system is still standing and, having died of fulminant polypoliticianemia, just isn't smart enough to fall over.

There is hope. As soon as big hosp, or the american hospital association, realize that medicare is not the symbiotic bliss they thought but is the people and paperwork parasite on the bottom line, will drop medicare and the mandates. And, when single payer medicine is voted in later this year, the corpse that is the medical system will finally fall over.

So kneel with me before the gods of patient satisfaction and pain control and pray it is over soon.

911, rough day? Sorry it has sucked. Your anger and frustration are palpable.

I hate watching this happen to you guys. It's the same helplessness I feel watching my dad working his ass off at his job as an accountant, where the company is owned by an investment firm. Those asshats could care less that they work him like he's 2 men, and they're killing him. They give no raises and raise the cost of his health insurance every year to cover the mobbed up, I mean union hourly workers. He's too old to go anywhere else, and he despises his job. He used to like what he did.

I'm having a crappy day too. My son crapped his pants twice and peed my floor twice today, and that was the good part of my day.

dear amy, thanks. correction, bad ten years. held this post for a few weeks to make sure i wanted it up and today's shift confirms. no worries here... i'm gone from the ER in three months. gonna sell out.

Yes, that sounds like a lot of pent-up frustration...So what are you going to do, if you can (want to) tell us?Surely, you are not leaving medicine altogether, that would be a huge waste after all those years of training and the $$$ spent.Can ER doctors "recycle" in another branch of medicine?

Ah sorry 911, didn't mean to denegrate your suffering. Just sounds like today has been a real crapper for you. But I guess it's been a real long while. That's so sad because I can see why one would like emergency medicine in a different world.

Can ya find one of those free standing ER thingies to work at? Do you think a clinic will be boring? But not so much crapola right?

i think ER will brighten again as there are lots like me who are leaving the titanic. eventually, unless we go completely off the board leftist then the market will correct for it and our pay will go up and our hours down. i just can't wait for that to happen.

amy, i don't know if i'll ever be full time ER again though i will continue to pull shifts as my skills, more than most (with the exception of surgeons) are perishable and if i get my head strait then i want to be able to come back.

yes, I thought the same as anonymous--wondered how you really REALLY felt. But isn't the problem that most ERs don't have the guts to send out the non-emergent stuff? Isn't EMTALA only supposed to cover care for 'emergent' conditions?? Just wondering.

good question. EMTALA was intended to prevent patient dumping for the old wallet-biopsy. actually, it was written, originally, specifically to cover women in labor "emergency treatment and active labor act" or something like that.

two problems. they included the language "emergency condition" but did not define it. and two, didn't fund it.

so, with the fear of litigation being a real fear ERs have tried but failed to do good triage and send the 'non emergency' patients packing. this with heavy fines ready to be handed out for improper triaging, and, as you know, the hardest nursing job in the world is triage.

the fall back position has been to just see everybody. in our particular state, even when a patient is judged to be 'non-emergent' and told to get lost they can refuse to leave and pay exactly 0$ for their care IF they have medicare/medicaid or our state insurance. self pay? you pay a copay. insurance? you pay a copay.

this has become well known over time and folks not only use us routinely for stuff that their PCPs CAN and SHOULD do for them (and do better for them than i can) but many have also dropped their PCPs because they have to pay them.

so emtala, in practice, means we see and treat all comers for anything regardless of their ability to pay or whether they are truly sick.

The 250 yard rule: This says that the Emergency Department extends 250 yards in every direction from the hospital property. Anyone who has an emergent condition and gets within 250 yards of the hospital property are to have the Emergency staff run out, with crash cart to tend to them. In our hospital, this means a freeway, 2 major intersections and half of a suspected meth house are part of the emergency department. Good news, if the patient keels over 251 yards away, we can call an ambulance.

The medical screen: Anyone who presents to the ER and asks for a medical screening exam gets one. EMTALA says you must do anything and everything to rule out an emergency. We are not allowed to ask any insurance or financial questions. So, if a patient comes in with an urgent condition, like a kidney stone, and asks if we take his insurance because he doesn't want a big bill, we cannot tell him. It is a violation of EMTALA. So he gets the CT of the abdomen because it could be an aneurysm, or bowel obstruction. And he gets a huge bill because we don't take his insurance. So the patient gets pissed at us.

And what do you do with the elderly parents who drive up and ask for a medical screen for the adult son that refuses the exam? EMTALA says the parents are allowed to ask for the screening exam and it must be done. But, we have to kidnap the patient out of the car to do it.

If we don't have the ability to treat a patient, EMTALA rules how to transfer the patient. If the patient has an intracranial hemorrhage, you need a place with a neurosurgeon. But, EMTALA accepts that if the receiving hospital has no available beds (in this case ICU beds), then the receiving hospital can decline the patient. So the patient, who might die without a neurosurgeon, sits in your ER while you go on to the next hospital, and the next, and the next. Then the next city, Then one of the four adjoining states. Hope the patient survives.

A study showed that EMTALA is slowing transfers by at least 1/2 hour.

And we are not even addressing the free care issue. Or the forcing the on call specialist to cancel his office full of paying customers to come to the hospital to care for one non-paying patient. Or the fact that the VA and military is exempt, so they can turn the ambulance away at the door.

Like I said before, an eagle of an idea sucked through the jet engine of government.

And, 911Doc, let me counsel you with the wise words of an old ER attending I once knew. He said that you may not get angry with the 1st patient, or 50th, or the 500th. But if you never get angry at a patient (or the system that enables him) and go off, you are not human. Take care, 911Doc

igloodoc, it just gets better and better doesn't it? well, i always wanted to play in the big game... shoot the game winning free throw... run for the winning touchdown... stand in the breach etc... so i've done my best to do just that for many years now and it's time for someone else to do it. thanks for your kind words. cheers

I don't understand the rant about being a little thrifty. Why did the author consider eating healthy and not wasting a bunch of gas in a truck ("Have fun driving your Prius and drinking soy and wheat-grass shakes.") to be some how anti-American?

If anything, sending excessive money to nations that hate us in exhange for oil so you can drive a bigass truck around isn't manly or American. Its stupid.

Uhhhh....anon 8:28, I think he was taking a well aimed, and well deserved jab at liberal beauracrats and their hyper- zealous fan club apopletically gyrating with their unrealistic idealism and social progressiveness that will shove our country into socialism and eventually communism faster than Michael Moore can cram a cheeseburger into his gaping maw if they are allowed to have their way with us.

Are other ER's (other than VA's, etc.) exempt from the EMTALA rules? Out in Middle-of-Nowhere-America we don't have an OB/BGYN within an 80 mile radius, so if a lady arrives at the ER in labor it's just an ambulance (or flight) to the nearest facility. Same with MRI's or casting broken bones, or anything involving a scalpel.

Actually, all we do here is pack 'em up and ship 'em out: 2 ER beds, and 8 hospital beds in the whole county. We're looking for staff if you're interested.

Nice one. Those of us living in our lovely socialist paradises (joking, really joking) wonder how a country that produces such smart people can produce such dumb laws. Hmmm lets see yes all can have health care and we won't need anyone to pay for it. Makes the communist party seem smart ;-)

Hey Anon..I live in the the Great Republic of Texas and I have 6 trucks. All of my family drives one.Suck my Dick!! If I want to pay for the gas, then I'll pay for it! When it's too expensive, I won't..Who's gonna win when we collide?!My kids are safe in them and that's worth a lot against all the freakin' ILLEGAL ALIENS here. Younger son, 18, drives F-150 King Ranch. Recently, ILLEGAL MEXICAN tried to run across 3 lanes of traffic at 55 mph, my son hit her and her CAR was totalled. Unless he pointed it out I wouldn't have known he was in a wreck.I guess I just narrowed myself down to about 25 million humanoids..

Hey anon, want to know why I drive a big truck? Back when I first started as an EMT we got called to a wreck. An illegal, who had no liscene and no job, who frequented the ER in the small town where I lived decided he would drive drunk in his small piece of shit pickup. He decided to cross the median on the interstate and run head on into a family in a very small car. It killed the dad (who was wearing a seatbelt) instantly. His wife, who was in her second trimester of pregnancy died. I could hear her gurgling, DROWNING, in her own blood as the FF's tried to cut her from the ball of metal that was once her car. There was a toddler in the back seat. We found him when we cut back the metal to get the mom out. He was completely unrecognizable.

Anonymous, I'm willing to pay for the saftey of driving a big truck. I'm confident that it will save me, my husband, and my unborn child if something happens.

dear ..., i would happily work for cash in a two room clinic if i could be the boss of me and involve the patients in their decisions and their care, and not have to fill out anything other than a handwritten patient encounter form. i could do 80 percent of what i do here in ten minutes and for thousands less. hey, i sound like a commercial.

oldfart, was cruising down the avenue today in my F150supercrew 4x4 when a 'smart' car passed me going the other direction. i am very concerned. that thing is so small i think it could get under my bumper and dent my fender or scratch my paint. do you know of any add-on brush-guard device designed specifically to crush the smart cars and prius and other go-cart type vehicles? i spent a lot getting that sniper rifle and 50cal airbrushed onto the side panels and i do NOT want that artwork damaged.

I don't think you would have to worry about the fine examples of hickart on the side panels of your hickcar, since go-carts would roll right under your bumper and end up in front of you anyway.As for the grille guards, they sell them at Bumpkin R'Us I am told.